How to Diagnose Androgen Excess in Postmenopausal Women

Androgen excess in postmenopausal women is a clinically underappreciated problem that can range from benign conditions to life-threatening malignancies. Because testosterone and other androgens naturally decline after menopause, any significant elevation deserves careful scrutiny — yet there has been a lack of standardized diagnostic guidance for this population.

This review article from the Androgens in Health and Disease Research Group at the Royal College of Surgeons in Ireland addresses that gap directly. The authors propose a comprehensive, step-by-step investigative approach that combines clinical presentation, biochemical testing, and radiological imaging to evaluate postmenopausal women presenting with signs of androgen excess such as hirsutism, acne, or voice deepening.

A central contribution of this work is the algorithmic decision-making framework, which organizes diagnostic steps around 'red flag' features — clinical or biochemical signals that raise concern for malignancy or an underlying genetic syndrome. The algorithm helps clinicians prioritize investigations and avoid unnecessary workup in lower-risk cases while ensuring dangerous causes are not missed.

The paper also reviews the physiological basis for how androgen production and metabolism change across the menopausal transition, providing essential context for interpreting lab results. Adrenal and ovarian sources of androgen excess are distinguished, as each requires a different diagnostic and management pathway.

For both clinicians and health-conscious patients, the key implication is that postmenopausal androgen excess should never be dismissed as a normal aging phenomenon without investigation. Early identification of underlying pathology — particularly adrenocortical carcinoma or ovarian stromal tumors — can be lifesaving. The framework offers practical, evidence-informed tools to navigate one of endocrinology's more diagnostically complex scenarios.