TL;DR

• Women with PCOS can be both hyperandrogenic or hypoandrogenic depending on symptoms 
• Testosterone has several bodily functions including reproductive/hormonal, energy levels, libido, bone and muscle development, cognitive functions and more. 
• Testosterone is produced in the ovaries and adrenal glands and is regulated by the hypothalamic-pituitary-gonadal (HPG) axis. Factors such as high insulin levels, and chronic stress can increase testosterone production in women with PCOS
• A combination of medications like spironolactone and combined oral contraceptives can help, while supplements and a balanced diet can support hormone regulation.
• Chronic stress over a lifetime (often associated with trauma), and endocrine disruptors can lead to persistent hormonal imbalance. Mindfulness practices, adequate sleep, and physical exercise are essential.

Introduction

One of the most common traits of PCOS is elevated testosterone.

Polycystic Ovarian Syndrome or PCOS impacts up to 8-10% of women in the US and 70% of women worldwide are undiagnosed meaning the actual number is much higher. 

PCOS is a chronic condition that’s defined as having excess androgens and/or chronic absence or lack of menstruation in the absence of adrenal and/or pituitary disease. 

In women with PCOS, elevated testosterone levels can lead to various symptoms and complications including irregular menstrual cycles, mood swings and emotion, weight gain and difficulty losing weight, dark patches of skin, infertility.

Please note that testosterone values may be normal in PCOS – it’s not necessary that all women with PCOS have this symptom. 

Even though there are many unwanted symptoms of elevated testosterone, please remember that testosterone as a whole has important bodily functions outside of hormone regulation and reproduction. It controls the proliferation of estrogen, encourages bone growth, increases skin collagen production, red blood cell production, and much more. 

Understanding testosterone’s role in your body will help you manage your mental health, prevent long term health risks, control body weight and much more. 

Please keep a holistic approach in mind before making drastic changes to lower testosterone.

What is Testosterone?

Testosterone is a crucial hormone in both men and women, though it is present in lower amounts in women. Outside of reproductive hormone regulation, Testosterone plays a role in muscle mass, bone density (both of which are needed for healthy aging), libido, and overall energy levels.

Testosterone is primarily produced in the ovaries and adrenal glands and is the precursor to estrogen. 

In reproductive aged women, 50% of testosterone conversion happens in the skin and fat tissues. 25% happens in the adrenals and 25% in ovaries. This means lifestyle modifications such as a healthy diet and regular exercise for weight management can significantly influence testosterone levels. 

Testosterone production is regulated through the hypothalamic-pituitary-gonadal (HPG) axis made up of the Hypothalamus, Pituitary Gland, and reproductive organs (Ovaries and Testes).  

Here is how these organ systems communicate to produce sex hormone testosterone. Keep in mind that in women, testosterone can be further converted to Estradiol (a type of estrogen).

1. Hypothalamus: releases gonadotropin-releasing hormone (GnRH) in response to stress, sleep, physical activity, and overall health status
2. Pituitary Gland: GnRH stimulates the anterior pituitary gland to secrete luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
3. Gonads (Ovaries and Testes): In response to LH, the testes in men and ovaries in women produce testosterone. In women, testosterone can be further converted to estrogen. FSH assists in the maturation of ovarian follicles in women.
   1. High levels of insulin (a common PCOS symptom) can stimulate the ovaries to produce more testosterone.

Lower androgen concentrations have been associated with bone loss for a range of age groups. 

High Testosterone Levels and PCOS

There are 2 types of testosterone to keep in mind: total testosterone and free testosterone

• Total testosterone measures testosterone that is bound to proteins and the testosterone that is free and active.
• Free testosterone is not bound to proteins (like sex hormone-binding globulin, SHBG) and is available to tissues. This is the biologically active form which is related to symptoms like hirsutism (excess hair growth), acne, and hair loss.

Both should be measured for a holistic understanding of what’s happening in the body. 

Source: Nordstrom

In women, normal total testosterone level ranges from 15-70 ng/dL (or 0.03 to 0.35 ng/dL free testosterone). Levels above this range are considered high and can lead to symptoms of hyperandrogegism.

Testosterone levels in females typically peak in the 30s-40s, and then begin to decline. Levels are highest in the mornings and fluctuate throughout the day. Throughout the menstrual cycle, testosterone levels peak right around ovulation and also right before menstruation.

Source: amcarehospital.com

Testosterone could be increased in women with PCOS because of 1) consistent high levels of Luteinizing hormone (LH) which happens due to polycystic ovaries that cause an imbalance of hormones 2) insulin increase and 3) chronic stress which leads to the production of DHEA (a weak form of androgen and a precursor to the production of testosterone). 

Higher levels of Testosterone is associated with the most pesky PCOS symptoms like acne, irregular periods, hirsutism, androgenic alopecia, increased waist circumference (and subsequent difficulty getting rid of belly fat), sleep disturbances, infertility challenges, and irritability and mood swings. 

Elevated testosterone is an issue to the extent the above symptoms disrupt your daily life and long term goals. 

Elevated Testosterone and the Mind

PCOS affects both the nervous and endocrine systems. The hypothalamus takes inputs from all parts of the body and the outside world and releases hormones that impact: 

• Sleep
• Sex drive & reproduction
• Temperature regulation
• Stress response
• Appetite and weight
• Emotions, behavior, and memory
• Heart rate
• Inflammatory response 

In response to chronic stress, the hypothalamus activates pathways that release Cortisol and DHEAs. Further, levels of LH, FSH, and SHBG (Sex Hormone-Binding Globulin) are also altered. 

Low grade chronic stress is caused by lifestyle pressures like poor sleep, self esteem issues, relationship tensions, fatigue, low self-reflection, mental health stigma, routine discomforts among numerous other factors. It’s very common among marginalized communities and populations that fall under low-socioeconomic brackets where stress may be normalized. 

Don’t ignore mild manifestations of these symptoms as they typically build up over time. The body and mind can adapt to ongoing stress, making it harder to recognize as a problem. Long term stress can cause havoc in the endocrine, cardiovascular, and immune systems. 

Be kind to yourself and start building greater awareness of your mind and behavior gradually. 

Low Testosterone Levels and PCOS

To some people’s surprise some lean PCOS women present with low testosterone though this is rare. 

New research seems to show the likelihood of a woman with low testosterone and low DHEAS likely due to insufficient adrenal androgen production. Please note that Testosterone naturally decreases as a woman ages 

Symptoms include but aren’t limited to: 

• Mood changes (depression, anxiety, irritability )
• Fatigue
• Low libido 
• Decreased Sexual Satisfaction
• Irregular Periods
• Vaginal Dryness
• Muscle Weakness 

Some causes of low testosterone in women with PCOS could be due to: 

• Medication Impact (metformin, spironolactone) 
• Lower than normal baseline levels
• Hypothalamic or Pituitary Dysfunction
• Coexisting Conditions such as hypothyroidism or adrenal insufficiency

How to Lower Testosterone Levels with PCOS

Before starting medications or treatments make sure you get a full lab work to baseline your hormone levels otherwise you won’t know if interventions are working. It’s also important to get the best personalized plan that works for your symptoms uniquely. 

Remember that symptoms of hyperandrogegism are often related to the free floating testosterone in the blood? This is the level of free testosterone that is not bound to Sex Hormone-Binding Globulin (SHBG). 

SHBG is produced by the Liver and levels are influenced by estrogen production, liver health, proper thyroid function, weight management, and insulin sensitivity.

According to Traditional Chinese Medicine, the Liver is the storehouse of blood and its flow is negatively impacted by emotional dysregulation such as anger, sadness/depression, worry and anxiety. It is regulated by joy and openness. 

Image Source: DAO Labs

When starting your treatment journey, keep an open mind to holistically understand your root causes. 

Here are several ways to regulate testosterone production based on your goals: 

Medicine

• Spironolactone: A diuretic with anti-androgenic effects, it blocks androgen receptors and inhibits enzymes involved in androgen production
  
• Combined Oral Contraceptives (COCs): These pills contain estrogen and progestin, which can suppress ovarian androgen production and reduce overall testosterone levels.
  
• Anti-Androgenic Progestins: Certain progestins, such as drospirenone, have anti-androgenic properties and can further help in reducing testosterone levels.
  
• Insulin Sensitizer: Commonly used in PCOS and diabetes, metformin improves insulin sensitivity, which can lower androgen levels, including DHEA and testosterone.

Lifestyle Adjustments

Supplements

• Vitamin D 
• Zinc Rich Foods: oysters, salmon, pumpkin seeds, beef, poultry, brown rice, lentils, greek yogurt. If supplementing, 8mg is the recommended daily dose. 
• Licorice Root: Contains compounds that can potentially reduce the conversion of DHEA to testosterone
• + 10 science backed supplements for PCOS

Diet & Nutrition 

Certain diet choices can influence insulin levels, inflammation, weight, and overall hormone imbalance, further exaggerating testosterone production. 

For example, adequate intake of healthy fats, proteins, and micronutrients like zinc and vitamin D is essential for hormone production. Here are other rules for foods to avoid or limit gradually: 

• Sugar (and high glycemic foods, see image below)
• Highly processed foods (fried food)  
• High salt 
• Starchy vegetables (white potatoes, corn, peas)
• Refined carbohydrates (mass-produced pastries and white bread
• Alcoholic beverages

Do add anti-inflammatory foods rich in omega-3 fatty acids, antioxidants, and phytoestrogens, which can help balance hormone levels.

Here’s a fuller deep dive on the do’s and don’ts of diet and nutrition for PCOS 

Body Movement & Physical Exercise

As we age we need increased mobility, strength, and flexibility to withstand pain, injury prevention, enhanced range of motion, joint health, and movement  

When it comes to lowering testosterone, greater physical activity helps muscle cells become more efficient in using glucose, reducing the need for high levels of insulin. This reduces the stimulation of ovarian testosterone production. 

Strength training and Yoga are great ways to start building endurance, mobility, posture, and flexibility. 

But, don’t just pick up physical exercise as a chore, pick what lights you up. Maybe instead of yoga you enjoy the movement of dance or the controlled movements of Pilates. Have fun along the way! 

Because weight is related to increasing insulin abnormalities it’s highly recommended to either lose it (or maintain it if you have lean PCOS)  

Here are some daily at home stretches to increase body mobility: 

Source: The Initial Mile

Stress Reduction

Chronic stress is at the core of persistent hormonal imbalances. Early childhood trauma, if left unexplored, can wreak havoc in our systems over a lifetime. Remember, it takes years to undo and relearn helpful habits. Gently push your awareness and body to grow beyond limiting beliefs everyday, especially with the help of a trained professional like a therapist or a psychiatrist.

Also note that trauma doesn’t have to feel extreme or life altering. In today’s society and environment, stressors are unavoidable and creep up and build up over time.

Educating ourselves and building awareness about your daily external and internal environment is key in creating a personalized toolkit. 

Here are some ways to get started:     

• Stress Reduction Techniques: Chronic stress increases adrenal production of DHEA. Techniques like mindfulness, meditation, yoga, and adequate sleep can reduce stress and lower DHEA levels.
  • Try Medito (free) or Headspace (paid), Calm (paid) 
  • Try a gratitude journal or develop a practice of journaling to get intimate with your worries and stress. 
• Limit Exposure to Endocrine Disruptors 

Source: Dr. Frank Lipman

• Dust and vacuum regularly
• Avoid fragrances 
• Avoid microwaving plastics
• Opt for products labeled as free from phthalates, parabens, and other known endocrine disruptors
• Reduce plastic use by swapping it out with reusables 
• Prioritize whole organic foods over processed foods 
• Use natural cleaning products
• Adaptogens: Herbal supplements like ashwagandha and rhodiola can help modulate the body’s stress response, potentially lowering adrenal androgen production.

Hair Loss Prevention & Treatment

Hair loss is related to confidence and mental health. Here’s what you need to know about hair loss related to elevated testosterone and PCOS and proven solutions for hair regrowth.