| name | endo-hirsutism-measure-dheas-adrenal-screen |
| description | Measure early morning serum DHEAS to screen for adrenal hyperandrogenism in women with hirsutism and normal total/free testosterone but clinical signs of androgen excess. Consider testing when there is suspicion of nonclassic congenital adrenal hyperplasia or adrenal tumor, especially in patients with high-risk ethnicity, family history, or progressive hirsutism despite normal ovarian androgen levels. |
Measure DHEAS to screen for adrenal hyperandrogenism
STEP 1 — Gather Information
Collect menstrual history, signs of virilization (clitoromegaly, deepening voice, rapid hirsutism progression), family history of adrenal disease, ethnicity, and physical exam findings (hirsutism score, acne, alopecia, Cushingoid features). Obtain early morning serum total testosterone, free testosterone, and DHEAS levels using a reliable specialty assay. Proceed to interpret testosterone results.
STEP 2 — Rule In / Rule Out
If total or free testosterone is elevated → ovarian or adrenal androgen excess likely; pursue further workup for tumor or PCOS per guideline. If both total and free testosterone are normal → proceed to assess adrenal contribution via DHEAS measurement.
STEP 3 — Classify or Stratify
Interpret DHEAS using age‑appropriate reference ranges: mild/moderate elevation (e.g., 200‑700 µg/dL) raises suspicion for nonclassic congenital adrenal hyperplasia (NCCAH); marked elevation (>700 µg/dL) suggests adrenal tumor or carcinoma. Normal DHEAS makes adrenal source unlikely but does not exclude NCCAH due to limited sensitivity. Decide next step based on DHEAS level.
STEP 4 — Decide
If DHEAS is markedly elevated (>700 µg/dL), order adrenal imaging (CT/MRI) and consider referral for possible adrenal tumor workup. If DHEAS is mildly/moderately elevated, obtain an early‑morning 17‑hydroxyprogesterone level (follicular phase or random day if amenorrhea) to evaluate for NCCAH. If DHEAS is normal, look elsewhere for androgen source (e.g., ovarian, medication‑related) and consider repeating testosterone assessment if clinical suspicion persists.
Clinical Guardrails / Mimics / Pitfalls
DHEAS has limited sensitivity for NCCAH; a normal level does not rule out adrenal hyperandrogenism, especially in mild cases. Do not rely solely on DHEAS to exclude adrenal source in women with clinical hyperandrogenism and normal testosterone. Avoid testing DHEAS in eumenorrheic women with only local hair growth and no abnormal hirsutism score, as yield is low. Be aware of assay variability and use a reliable specialty assay; do not substitute DHEAS for 17‑OH progesterone when NCCAH is suspected.
Concrete Clinical Example
A 28‑year‑old woman presents with Ferriman‑Gallwey score 12, regular menses, mild acne, and normal total and free testosterone. She reports a sister with congenital adrenal hyperplasia. DHEAS returns at 260 µg/dL (mildly elevated). An early‑morning 17‑hydroxyprogesterone is 210 ng/dL (elevated), leading to a diagnosis of nonclassic congenital adrenal hyperplasia; she is started on low‑dose glucocorticoid therapy with improvement in hirsutism over 6 months.
Source: Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, 10.1210/jc.2018-00241
