Androgen Dominance

What It Is

Androgen dominance is a hormonal imbalance where androgens (male hormones, primarily testosterone and DHEA) are elevated relative to estrogen and progesterone. This can occur as an absolute elevation (androgens are higher than normal) or a relative elevation (androgens are normal or even low, but estrogen/progesterone have declined faster, creating an imbalance).

What are androgens?

Androgens are hormones traditionally considered "male hormones," but women produce and need androgens too—just in smaller amounts than men.

Primary androgens in women:

• Testosterone → produced by ovaries (25%), adrenal glands (25%), and peripheral conversion from other hormones (50%)

  • Supports libido, energy, motivation, muscle mass, bone density, confidence, assertiveness
  • Normal range in premenopausal women: 15-70 ng/dL (varies by lab and assay)

• DHEA (dehydroepiandrosterone) → produced primarily by adrenal glands

  • Precursor to testosterone and estrogen
  • Supports energy, resilience, immune function, mood
  • Declines with age (peaks in 20s, declines steadily thereafter)

• Androstenedione → precursor to testosterone and estrogen, produced by ovaries and adrenals

• DHT (dihydrotestosterone) → most potent androgen, converted from testosterone by the enzyme 5-alpha-reductase

  • Responsible for "androgenic" effects: facial/body hair growth, scalp hair loss, acne, oily skin

How androgen dominance develops:

Absolute androgen dominance (androgens are elevated):

1. Polycystic Ovary Syndrome (PCOS) → most common cause in reproductive years

   • Ovaries produce excess testosterone (often driven by insulin resistance)
   • Affects 5-10% of women of reproductive age

2. Insulin resistance → high insulin stimulates ovaries to produce more testosterone and lowers SHBG (sex hormone binding globulin), increasing free (active) testosterone

3. Adrenal androgen excess → adrenal glands overproduce DHEA, androstenedione (less common, can be stress-related or due to adrenal tumors)

4. Ovarian or adrenal tumors → rare, but can produce excess androgens

Relative androgen dominance (androgens normal or low, but estrogen/progesterone declined faster):

1. Perimenopause/menopause → estrogen and progesterone decline faster than testosterone

   • Testosterone may be normal or even declining, but the ratio shifts toward androgens
   • Common pattern in early perimenopause: progesterone declines first → androgen-to-progesterone ratio increases

2. SHBG decline → SHBG binds to testosterone and keeps it inactive; when SHBG drops (due to insulin resistance, low estrogen, or aging), more testosterone becomes "free" (active)

   • Total testosterone may be normal, but free testosterone is elevated → androgen symptoms

Why the ratio matters more than absolute levels:

Hormones work in balance. It's not just about how much testosterone you have—it's about how much testosterone you have relative to estrogen and progesterone.

• High estrogen + moderate testosterone = balanced (no androgen symptoms)
• Low estrogen + moderate testosterone = androgen dominance (relative excess)
• High testosterone + normal estrogen = androgen dominance (absolute excess)

Why It Matters During Perimenopause/Menopause

Androgen dominance is common during perimenopause, and it's often misunderstood or dismissed. Many women are surprised to develop "teenage" symptoms (acne, oily skin) in their 40s and 50s—but the hormonal shifts of perimenopause create the perfect conditions for androgen dominance.

Why androgens become dominant in perimenopause:

1. Progesterone declines first (early perimenopause):

   • Progesterone normally balances testosterone (has anti-androgenic effects)
   • When progesterone drops, testosterone's effects become more pronounced
   • Result: Acne, oily skin, facial hair, irritability—even if testosterone levels haven't changed

2. Estrogen fluctuates and eventually declines:

   • Estrogen normally balances testosterone and supports SHBG production
   • When estrogen declines, SHBG declines → more free (active) testosterone
   • Result: Androgen symptoms intensify

3. Testosterone declines more slowly than estrogen/progesterone:

   • Testosterone production decreases with age, but the decline is gradual (not as dramatic as estrogen's decline)
   • In perimenopause: Estrogen and progesterone may drop 50-90%, while testosterone drops 20-50%
   • Result: Testosterone becomes dominant relative to estrogen/progesterone

4. Insulin resistance worsens in perimenopause:

   • Declining estrogen reduces insulin sensitivity → insulin resistance develops
   • High insulin stimulates ovaries to produce more testosterone
   • High insulin lowers SHBG → more free testosterone
   • Result: Androgen symptoms worsen (acne, hair growth, hair loss, weight gain)

5. Adrenal androgen production continues:

   • After menopause, ovaries produce very little testosterone, but adrenal glands continue producing DHEA and androstenedione (which convert to testosterone)
   • If adrenals are overactive (due to chronic stress), androgen production may be higher → androgen dominance persists

The common patterns:

Early perimenopause (progesterone drops first):

• Androgen symptoms emerge: acne (especially jawline, chin), oily skin, occasional facial hair
• Mood changes: irritability, impatience, reduced tolerance for nonsense
• Cycles may be shorter, heavier, or irregular

Mid-perimenopause (estrogen fluctuates, insulin resistance worsens):

• Androgen symptoms intensify: persistent acne, noticeable facial hair (upper lip, chin, sideburns), scalp hair thinning
• Abdominal weight gain (insulin resistance + androgen dominance)
• Energy may be good (testosterone supports energy), but mood is volatile

Late perimenopause/early menopause (estrogen very low, testosterone relatively higher):

• Androgen symptoms may peak or stabilize
• Scalp hair thinning becomes more noticeable
• Facial hair continues to increase
• Muscle mass may be better preserved than women with low androgens (testosterone supports muscle)

Post-menopause (without HRT):

• Androgen dominance may persist if insulin resistance is not addressed
• Women on estrogen therapy often see androgen symptoms improve (estrogen restores balance, raises SHBG)

How It Works

Mechanism of androgen dominance:

Androgens exert their effects by binding to androgen receptors throughout the body (skin, hair follicles, muscles, bones, brain, genitals). When androgen levels are elevated (absolutely or relatively), these receptors are overstimulated.

Key pathways:

1. Testosterone and DHT (dihydrotestosterone):

• Testosterone is converted to DHT by the enzyme 5-alpha-reductase (present in skin, scalp, hair follicles)
• DHT is 5-10x more potent than testosterone at binding androgen receptors
• DHT is responsible for most "androgenic" effects:
  • Scalp hair follicles: DHT shrinks follicles → hair thinning, hair loss (androgenic alopecia)
  • Facial/body hair follicles: DHT stimulates growth → hirsutism (excess hair on face, chest, abdomen)
  • Sebaceous glands (skin): DHT stimulates oil production → oily skin, acne
  • Prostate (in men), not relevant in women

2. Insulin and testosterone:

• High insulin stimulates ovaries to produce more testosterone (via LH receptors)
• High insulin lowers SHBG → SHBG binds testosterone and keeps it inactive; low SHBG = more free (active) testosterone
• Vicious cycle:
  • Insulin resistance → high insulin → high testosterone + low SHBG → more androgen symptoms
  • High androgens worsen insulin resistance (impair glucose metabolism) → cycle continues

3. SHBG (sex hormone binding globulin):

• SHBG is a protein that binds to sex hormones (testosterone, estrogen) and keeps them inactive
• High SHBG → more hormones are bound (inactive) → less free (active) hormones → fewer symptoms
• Low SHBG → more hormones are free (active) → more symptoms

What lowers SHBG:

• Insulin resistance, high insulin
• Low estrogen (estrogen stimulates SHBG production)
• Hypothyroidism
• Obesity (especially visceral fat)
• Oral contraceptives (depending on type)

What raises SHBG:

• Estrogen therapy (oral estrogen is most effective at raising SHBG)
• Weight loss, improved insulin sensitivity
• Thyroid optimization
• High-fiber diet

4. Progesterone's anti-androgenic effects:

• Progesterone has weak anti-androgenic effects → competes with testosterone at receptors, reduces 5-alpha-reductase activity (less DHT production)
• When progesterone declines (perimenopause), this protective effect is lost → androgen symptoms emerge

5. Estrogen's balancing effects:

• Estrogen increases SHBG → binds testosterone, reduces free testosterone
• Estrogen balances testosterone's effects on mood, energy, skin, hair
• When estrogen declines, testosterone's effects become more pronounced

6. Adrenal androgens and stress:

• Chronic stress increases cortisol (stress hormone) and DHEA (adrenal androgen)
• High DHEA converts to testosterone → can contribute to androgen dominance
• Some women have high cortisol + high DHEA ("stressed and wired" pattern) → androgen symptoms
• Others have high cortisol + low DHEA ("stressed and tired" pattern) → fewer androgen symptoms, more fatigue

What It Looks Like

Absolute Androgen Dominance (Elevated Androgens)

Most common in PCOS, insulin resistance, adrenal androgen excess

Physical:

• Acne → especially jawline, chin, chest, back ("hormonal acne" pattern)
• Oily skin → face feels greasy, enlarged pores
• Hirsutism → excess facial/body hair (upper lip, chin, sideburns, chest, abdomen, inner thighs)
• Scalp hair thinning → androgenic alopecia (hair loss at crown, temples, widening part)
• Abdominal weight gain → "apple shape" (often coexists with insulin resistance)
• Irregular periods → anovulatory cycles (no ovulation), long cycles, or amenorrhea (no periods)
• Deepening voice → rare, suggests very high androgens (more common in PCOS with very high testosterone or androgen-producing tumor)
• Increased muscle mass → easier to build muscle (testosterone supports muscle growth)

Cognitive:

• Sharp thinking, confidence → testosterone supports cognitive clarity, assertiveness
• Motivation, drive → high androgens can enhance productivity, ambition

Emotional:

• Irritability, impatience → low frustration tolerance
• Reduced emotional sensitivity → less empathy, more direct/blunt communication
• Assertiveness, dominance → less conflict-avoidant, more willing to assert boundaries
• Libido may be high or normal (testosterone supports libido)

Lab markers:

• Total testosterone: > 70 ng/dL (elevated for women; varies by lab)
• Free testosterone: > 2.5% of total, or > 1.5 pg/mL (elevated)
• DHEA-S: > 350 mcg/dL (elevated; varies by age and lab)
• Androstenedione: > 250 ng/dL (elevated)
• SHBG: < 30 nmol/L (low)
• LH-to-FSH ratio: > 2:1 (suggests PCOS)
• Fasting insulin: > 10-15 mIU/L (suggests insulin resistance)

Relative Androgen Dominance (Normal or Low Androgens, But Low Estrogen/Progesterone)

Most common in perimenopause/menopause

Physical:

• Acne → sudden onset or worsening in 40s/50s (often surprising—"I haven't had acne since high school!")
• Oily skin → skin becomes greasier than it was in 30s
• Facial hair → increased growth (upper lip, chin), darker/coarser hair
• Scalp hair thinning → hair becomes finer, thinner, more shedding (though may be less dramatic than absolute androgen dominance)
• Abdominal weight gain → especially if insulin resistance is present
• Irregular periods → cycles become erratic as estrogen/progesterone fluctuate

Cognitive:

• Variable → may have sharp thinking (testosterone supports cognition), but if estrogen is very low, brain fog may still be present

Emotional:

• Irritability → reduced patience, lower tolerance for frustration
• Assertiveness → less automatic agreeableness, more willing to say "no"
• Boundary crystallization → clearer sense of personal limits, less tolerance for emotional labor
• Libido may be variable → testosterone supports libido, but if estrogen is very low, arousal and vaginal lubrication may be impaired

Lab markers:

• Total testosterone: 15-70 ng/dL (normal range, but may be at higher end)
• Free testosterone: Normal or slightly elevated (due to low SHBG)
• Estradiol: < 50 pg/mL (low, varies by cycle phase or menopausal status)
• Progesterone: < 3 ng/mL (low or absent if anovulatory)
• SHBG: < 30-40 nmol/L (low, often due to insulin resistance or low estrogen)
• Fasting insulin: > 10 mIU/L (suggests insulin resistance)

When Androgens Are Optimal (Balanced)

Physical:

• Clear skin (no acne, normal oil production)
• Healthy hair (no excessive facial/body hair, full scalp hair)
• Healthy body composition (muscle mass maintained, minimal visceral fat)
• Regular, predictable cycles (if premenopausal)

Cognitive:

• Clear thinking, sharp focus
• Motivation, drive, confidence (without irritability or aggression)

Emotional:

• Assertiveness balanced with empathy
• Healthy libido and arousal
• Emotional resilience without emotional numbing
• Boundaries without rigidity

Lab markers:

• Total testosterone: 15-50 ng/dL (mid-range for women)
• Free testosterone: < 2.0% of total, or < 1.5 pg/mL
• DHEA-S: 100-300 mcg/dL (age-dependent; declines with age)
• Estradiol: 50-200 pg/mL (varies by cycle phase; in menopause, optimal on HRT is 50-100 pg/mL)
• Progesterone: > 5 ng/mL in luteal phase (if ovulating)
• SHBG: 40-120 nmol/L (optimal range)
• Fasting insulin: < 5-10 mIU/L (optimal)

Phase Impact

Baseline (Regular Cycle, Pre-Perimenopause): Androgens are balanced with estrogen and progesterone. Testosterone supports healthy libido, energy, muscle mass, bone density, confidence. SHBG is adequate (estrogen supports SHBG production). Skin is clear, hair is healthy. Androgen dominance is uncommon unless PCOS or insulin resistance is present.

Electric Cougar (Early Perimenopause): Progesterone begins to decline (anovulatory cycles more frequent) → androgen-to-progesterone ratio increases → androgen symptoms may emerge. Acne appears (often jawline/chin), skin becomes oilier, facial hair may increase. Insulin resistance may develop → lowers SHBG → increases free testosterone. Some women experience increased confidence, assertiveness, irritability. Libido may surge (testosterone + estrogen both still present).

Wild Tide (Mid-Perimenopause): Estrogen fluctuates wildly, progesterone is inconsistent, testosterone declines gradually → androgen-to-estrogen ratio becomes more variable. Androgen symptoms may intensify or fluctuate. Acne persists or worsens. Facial hair becomes more noticeable. Scalp hair thinning begins. Insulin resistance worsens → androgen symptoms worsen. Mood is volatile (irritability, impatience). Boundary crystallization is common (low progesterone + relative androgen dominance).

Henapause (Late Perimenopause, 7-11 Months Without Period): Estrogen is consistently low, progesterone is absent, testosterone is relatively higher → androgen dominance may be at its peak. Acne may persist or improve (depends on individual hormonal pattern). Facial hair continues to increase. Scalp hair thinning is noticeable. Insulin resistance is common → SHBG is low → free testosterone is elevated. This is a critical window for addressing insulin resistance and considering HRT (estrogen therapy raises SHBG and balances androgens).

The Pause (Menopause, 12+ Months Without Period): Estrogen stabilizes at low levels, testosterone continues to decline (but more slowly than estrogen). Androgen dominance may persist if insulin resistance is not addressed or if adrenal androgens are elevated. Women on estrogen therapy often see androgen symptoms improve (estrogen raises SHBG, restores hormonal balance). Those not on HRT may continue to struggle with acne, facial hair, scalp hair thinning.

Phoenix Phase (Early Post-Menopause, 2-10 Years After Last Period): Testosterone declines further (ovarian production minimal, relying on adrenal production). Androgen dominance is less common unless insulin resistance or adrenal androgen excess persists. Women on HRT with balanced estrogen/progesterone/testosterone have optimal androgen levels. Those with persistent androgen symptoms should address insulin resistance and consider anti-androgen therapy or HRT.

Golden Sovereignty (Established Post-Menopause, 7+ Years After Last Period): Testosterone is low (adrenal production continues but ovarian production has ceased). Androgen dominance is uncommon unless driven by insulin resistance or adrenal dysfunction. Women on testosterone therapy (if deficient) report improved energy, libido, muscle mass, mood. Those with history of androgen dominance often see symptoms resolve with age (as testosterone declines) or with HRT (estrogen restores balance).

Testing & Optimization

When to Test

Testing is valuable if you suspect androgen dominance (acne, facial hair, scalp hair loss, oily skin, irregular cycles).

Comprehensive androgen panel:

• Total testosterone → measures all testosterone (bound + free)

  • Normal range: 15-70 ng/dL (varies by lab and assay)
  • Note: Range is wide; symptoms matter more than numbers

• Free testosterone → measures unbound (active) testosterone

  • Can be directly measured or calculated from total testosterone and SHBG
  • More clinically relevant than total testosterone (free = active)

• DHEA-S → adrenal androgen, precursor to testosterone

  • Normal range: 35-430 mcg/dL (declines with age; 20s may be 200-400, 50s may be 50-200)

• Androstenedione → precursor to testosterone and estrogen

  • Normal range: 30-250 ng/dL

• SHBG → binds to sex hormones; low SHBG = more free testosterone

  • Normal range: 20-120 nmol/L
  • Optimal: 40-120 nmol/L

• DHT (dihydrotestosterone) → most potent androgen (optional test, not routinely ordered)

  • Normal range: 2-25 pg/mL

Supporting tests:

• Estradiol (E2) → to assess estrogen-to-androgen ratio
• Progesterone → to assess progesterone-to-androgen ratio (test on day 21 of cycle if still cycling)
• Fasting insulin, fasting glucose, A1C → to assess insulin resistance (common driver of androgen dominance)
• LH, FSH → if PCOS suspected (LH-to-FSH ratio > 2:1 suggests PCOS)
• 17-hydroxyprogesterone → if adrenal androgen excess suspected (elevated in congenital adrenal hyperplasia)

When to test:

• If experiencing acne, oily skin, facial/body hair growth, scalp hair thinning
• If irregular cycles, absent cycles, or suspected PCOS
• At perimenopause onset (baseline)
• If developing androgen symptoms during perimenopause
• Before starting HRT (to assess baseline and guide treatment)
• If on HRT and androgen symptoms persist (may need dose adjustment or anti-androgen therapy)

Optimization Strategies

1. Address Insulin Resistance (Most Effective for Many Women)

Insulin resistance is the most common driver of androgen dominance in perimenopause.

Strategies:

• Low-carbohydrate or moderate-carbohydrate diet → reduces insulin demand, improves insulin sensitivity
• Strength training → builds muscle, improves insulin sensitivity
• Metformin (500-2000 mg daily) → improves insulin sensitivity, lowers testosterone, raises SHBG (especially effective in PCOS)
• Weight loss (if overweight) → improves insulin sensitivity, lowers androgens, raises SHBG
• Inositol (myo-inositol 2-4 g daily) → improves insulin sensitivity, lowers testosterone (effective in PCOS)

See insulin-resistance entry for comprehensive strategies.

2. Hormone Replacement Therapy (HRT)

Estrogen therapy (especially oral estrogen):

• Raises SHBG → binds testosterone, reduces free testosterone
• Restores estrogen-to-androgen balance → androgen symptoms often improve significantly
• Oral estrogen is most effective at raising SHBG (transdermal estrogen raises SHBG less, but is safer for cardiovascular/metabolic health)
• Many women see acne, facial hair, and scalp hair loss improve on estrogen therapy

Progesterone therapy:

• Bioidentical progesterone has mild anti-androgenic effects (reduces 5-alpha-reductase activity)
• Can help with androgen symptoms, especially if progesterone is deficient

Testosterone therapy (if needed):

• Some women need low-dose testosterone for libido, energy, muscle mass
• Must be carefully dosed (too much worsens androgen symptoms)
• Monitor free testosterone to ensure it stays in optimal range

3. Anti-Androgen Medications

Spironolactone:

• Anti-androgen medication (blocks androgen receptors, reduces testosterone production)
• Dose: 50-200 mg daily
• Highly effective for acne, facial hair, scalp hair loss
• Side effects: Increased urination (it's also a diuretic), low blood pressure, hyperkalemia (high potassium—avoid if kidney issues)
• Can be used with or without HRT
• Note: Not suitable if trying to conceive (can affect male fetus development)

Finasteride:

• 5-alpha-reductase inhibitor (blocks conversion of testosterone to DHT)
• Dose: 1-5 mg daily
• Effective for scalp hair loss (less effective for acne or facial hair)
• Side effects: Rare in women (more commonly used in men for hair loss and prostate issues)
• Can be used with or without HRT

Oral contraceptives (if premenopausal):

• Birth control pills suppress ovarian androgen production and raise SHBG
• Anti-androgenic progestins (drospirenone, cyproterone acetate) are most effective
• Androgenic progestins (levonorgestrel, norethindrone) can worsen androgen symptoms—avoid
• Not appropriate in perimenopause for many women (increases clot risk, masks menopausal symptoms)

4. Topical Treatments (For Skin and Hair)

For acne:

• Topical retinoids (tretinoin, adapalene) → unclog pores, reduce oil production, promote skin turnover
• Topical antibiotics (clindamycin, erythromycin) → reduce acne-causing bacteria
• Benzoyl peroxide → kills bacteria, reduces inflammation
• Azelaic acid → anti-inflammatory, reduces oil production
• Salicylic acid → exfoliates, unclogs pores

For facial hair:

• Eflornithine (Vaniqa) → topical cream that slows facial hair growth (must use continuously; hair returns when stopped)
• Hair removal: Laser hair removal, electrolysis (permanent), waxing, threading, shaving (temporary)

For scalp hair loss:

• Minoxidil (Rogaine) → topical solution that stimulates hair growth (2% or 5% solution, applied daily)
  • Takes 3-6 months to see results; hair loss resumes if stopped
• Low-level laser therapy (LLLT) → red light therapy devices may stimulate hair growth (evidence is mixed)

5. Nutritional Support

Anti-inflammatory diet:

• Reduces inflammation that worsens insulin resistance and androgen production
• Whole foods, healthy fats, quality protein, abundant vegetables
• Limit: sugar, refined carbs, processed foods, dairy (some women find dairy worsens acne)

Spearmint tea:

• 2 cups daily → may reduce androgens (small studies show reduction in testosterone in women with PCOS/hirsutism)
• Mechanism: unknown, possibly anti-androgenic effects

Saw palmetto:

• 160-320 mg daily → may block 5-alpha-reductase (reduces DHT)
• Evidence is mixed; more research needed

Zinc:

• 15-30 mg daily → may reduce 5-alpha-reductase activity, supports skin health

Omega-3 fatty acids:

• 1-2 g EPA/DHA daily → reduces inflammation, may improve insulin sensitivity

6. Lifestyle Optimization

Stress management:

• Chronic stress elevates cortisol and DHEA (adrenal androgens) → can worsen androgen dominance
• Practices: meditation, breathwork, therapy, boundaries, nervous system regulation

Sleep:

• Poor sleep worsens insulin resistance, cortisol dysregulation → worsens androgen dominance
• 7-9 hours of quality sleep

Exercise:

• Strength training → improves insulin sensitivity, supports healthy body composition
• Avoid over-exercising → excessive exercise raises cortisol, can worsen androgen symptoms

When to Review with Clinician

You should discuss androgen dominance if:

• Acne (especially jawline, chin, chest, back)
• Oily skin, enlarged pores
• Facial hair growth (upper lip, chin, sideburns)
• Scalp hair thinning or hair loss
• Irregular or absent periods (if premenopausal)
• Abdominal weight gain, difficulty losing weight
• Signs of insulin resistance (dark skin patches, skin tags, elevated fasting glucose/insulin)
• Family history of PCOS or insulin resistance
• Interested in testing androgens, SHBG, insulin
• Considering anti-androgen therapy (spironolactone, finasteride)
• On HRT but androgen symptoms persist

Red flags requiring medical attention:

• Sudden, severe hirsutism (rapid onset of facial/body hair) → possible androgen-producing tumor (rare)
• Deepening voice, clitoral enlargement, severe acne → very high androgens, requires evaluation
• Severe insulin resistance, prediabetes, or type 2 diabetes (fasting glucose ≥ 100 mg/dL, A1C ≥ 5.7%)
• Irregular periods with infertility (if trying to conceive) → PCOS evaluation and treatment

Related Terms

• testosterone
• estrogen
• progesterone
• insulin-resistance
• insulin
• shbg
• dhea
• pcos
• acne
• hirsutism
• hair-loss
• boundary-crystallization
• the-patience-gap