Understanding PCOS & High Androgen Symptoms

Millions of women experience the symptoms of PCOS: acne, irregular cycles, fatigue, hair changes, yet never receive a clear diagnosis or the support they need.

Whether you've been diagnosed, dismissed, or feel stuck between the lines, we hope this page will help you understand what may be driving your symptoms… and what you can do about it.

What is PCOS?

Polycystic Ovary Syndrome (PCOS) is one of the most common hormone conditions, affecting an estimated 10-15% of reproductive age women. It’s a metabolic and hormonal spectrum characterized by irregular or absent ovulation, signs of high androgens (acne, excess hair, hair loss, oily skin), and ovarian changes on ultrasound.

A woman doesn’t need all three to be diagnosed. Different medical systems use different criteria, which is one reason diagnosis is so inconsistent.

Below is a breakdown of the different diagnostic methods used, Rotterdam being the most common:
Rotterdam Diagnostic Criteria

For adult women, PCOS is diagnosed if you have 2 out of these 3, after ruling out other causes (like thyroid issues, high prolactin, non-classic CAH, etc.):

1. Androgen excess

  • Clinical: acne, hirsutism (chin/jaw hair, chest, abdomen), androgenic hair loss, oily skin.
  • Or biochemical: elevated testosterone, free androgen index, etc. on bloodwork.

2. Ovulatory dysfunction

  • Irregular cycles (usually >35 days)
  • Very long cycles
  • Or absent periods (oligo- or amenorrhea).

3. Polycystic ovaries on ultrasound or high AMH

  • Ultrasound: increased follicle number / “polycystic ovarian morphology.”
  • Some newer guidelines also accept high AMH as a proxy for polycystic ovaries.

You only need 2 of the 3.
That’s why someone can have:

  • Irregular periods + high androgens, without cysts on ultrasound → still PCOS.
  • Cystic-looking ovaries + irregular periods, but normal androgens → still PCOS.

This system creates 4 “phenotypes” (A-D) depending on which combo you have.

NIH Criteria

A stricter, older standard for diagnosis. It requires both to be present:

1. Ovulatory dysfunction

  • Irregular cycles (<21 or >35 days)
  • Fewer than 8 cycles per year
  • Cycles that fluctuate widely
  • No periods for 90+ days
  • Anovulation detected on bloodwork (low progesterone)

2. Androgen excess

  • Clinical: Acne, Hirsutism (chin/jaw, chest, abdomen), Androgenic alopecia (hair thinning), Oily skin
  • Biochemical: High total testosterone, High free testosterone, Elevated free androgen index, High DHEA-S (adrenal androgen)
AE-PCOS Society Criteria

What it requires:

1. Androgen excess is mandatory

2. Plus EITHER:

  • Ovulatory dysfunction
  • OR Polycystic ovarian morphology

How it’s used:
This system views PCOS as fundamentally an androgen-driven condition. People without high androgens (e.g., phenotype C or D) are not diagnosed under this method.

What are High Androgens?

Androgens (like testosterone and DHEA-S) are hormones that all women produce in small amounts.
But when levels rise above what’s typical, or when the body becomes more sensitive to them, symptoms can appear:

  • acne
  • unwanted hair growth
  • scalp hair thinning
  • oily skin
  • irregular cycles

This is called androgen excess or “high androgens.” Not everyone with PCOS experiences high androgens, and not everyone with high androgens receives a PCOS diagnosis.
Clinical HA (visible symptoms)

Clinical hyperandrogenism alone is enough to meet the “androgen excess” criterion for PCOS, even if labs are normal.

Primary clinical signs:

1. Hirsutism (excess hair growth in androgen-sensitive areas)

  • Chin/jawline
  • Upper lip
  • Chest
  • Abdomen
  • Inner thighs
  • Based on Ferriman-Gallwey scoring (≥8 is typically considered abnormal)

2. Acne, especially:

  • Jawline, chin, chest, back
  • Persistent or cystic acne in adulthood

3. Androgenic alopecia (hair thinning)

  • Thinning at the crown
  • Widening part
  • “Diffuse” thinning in women

4. Seborrhea / oily skin
Biochemical HA (lab abnormalities)

This involves bloodwork showing elevated androgens. A woman is considered hyperandrogenic if any one biochemical marker is elevated, not all.

Common labs used:

  • Total testosterone
  • Free testosterone (most sensitive)
  • Free androgen index (FAI)
  • Sex hormone-binding globulin (SHBG) (low SHBG → more free testosterone)
  • DHEA-S (adrenal androgen)
  • Androstenedione

What counts as “high”?
Cutoffs vary by lab because reference ranges differ, but typical diagnostic thresholds include:

1. Total Testosterone

  • Levels above the lab’s upper reference limit
  • Often >50-60 ng/dL, depending on the lab
  • In lean PCOS, may be normal even with symptoms

2. Free Testosterone

  • Most accurate indicator
  • High if above lab’s upper limit
  • Commonly >4-6 pg/mL, depending on assay sensitivity

3. Free Androgen Index (FAI)

  • FAI = (Total T / SHBG) × 100
  • FAI > 5-7 in women usually indicates hyperandrogenism

DHEA-S

  • Elevated above age-adjusted upper limit
  • Very high levels suggest adrenal involvement (adrenal-type PCOS or rule-out conditions)

Androstenedione

  • Elevated above reference range
  • Often high in PCOS even when testosterone isn’t

PCOS vs HA

Women with a PCOS diagnosis

Many, but not all, women with PCOS have androgen excess. 60-80% of women with PCOS show elevated androgens, while 20-40% do not.

Women with high androgen symptoms

You can have high-androgen symptoms without meeting the strict criteria for PCOS. This is extremely common and often overlooked.

Women with a PCOS diagnosis

Many, but not all, women with PCOS have androgen excess. 60-80% of women with PCOS show elevated androgens, while 20-40% do not.

Women with high androgen symptoms

You can have high-androgen symptoms without meeting the strict criteria for PCOS. This is extremely common and often overlooked.