| name | endo-hirsutism-test-androgen-levels-abnormal-score |
| description | Measures serum total and/or free testosterone in women with an abnormal Ferriman–Gallwey hirsutism score to evaluate for hyperandrogenemia. Triggered when a clinician wonders whether to check androgen levels because the patient's hirsutism score exceeds the population cutoff. |
Test androgen levels when hirsutism score is abnormal
STEP 1 — Gather Information
Collect patient's Ferriman–Gallwey hirsutism score (assess nine androgen-sensitive areas: upper lip, chin, chest, upper abdomen, lower abdomen, upper back, lower back, upper thighs, thighs; each 0-4). Determine if score is above population-specific cutoff (≥8 for US white/black women, ≥9-10 for Mediterranean/Hispanic/Middle Eastern, ≥6 for South American, ≥2-7 for Asian). Also note menstrual regularity, presence of clinical hyperandrogenism signs (acne, alopecia), and any medications that affect androgen levels.
STEP 2 — Rule In / Rule Out
Is the Ferriman–Gallwey score abnormal (above cutoff)? If yes, proceed to measure androgen levels. If no, do not test for elevated androgen levels (unless other clinical evidence of hyperandrogenic disorder exists).
STEP 3 — Classify or Stratify
If total testosterone is normal but sexual hair growth is moderate/severe or mild with clinical evidence of hyperandrogenic disorder (e.g., menstrual disturbance, progression despite therapy), measure free testosterone using a reliable specialty assay (equilibrium dialysis or calculated free testosterone using SHBG and albumin). If total testosterone is elevated, hyperandrogenemia is confirmed.
STEP 4 — Decide
If androgen levels (total or free) are elevated, evaluate for underlying hyperandrogenic etiologies (PCOS, NCCAH, androgen-secreting tumor, Cushing's, etc.). If normal and no other clinical hyperandrogenism signs, consider idiopathic hirsutism and proceed with cosmetic or pharmacologic therapy as appropriate.
Clinical Guardrails / Mimics / Pitfalls
Do not test androgen levels in eumenorrheic women with only unwanted local hair growth (no abnormal hirsutism score) due to low yield. Avoid relying on total testosterone alone in women with mild hirsutism; free testosterone may be more sensitive. Be aware of assay limitations: use reliable specialty assays, avoid immunoassays prone to interference at low female levels. Do not mistake hypertrichosis (generalized nonsexual hair) for hirsutism. Consider medications (valproximately 100 lines total. Let's count lines.
We'll produce final.
name: endo-hirsutism-test-androgen-levels-abnormal-score
description: Measures serum total and/or free testosterone in women with an abnormal Ferriman–Gallwey hirsutism score to evaluate for hyperandrogenemia. Triggered when a clinician wonders whether to check androgen levels because the patient's hirsutism score exceeds the population cutoff.
Test androgen levels when hirsutism score is abnormal
STEP 1 — Gather Information
Collect patient's Ferriman–Gallwey hirsutism score (assess nine androgen-sensitive areas: upper lip, chin, chest, upper abdomen, lower abdomen, upper back, lower back, upper thighs, thighs; each 0-4). Determine if score is above population-specific cutoff (≥8 for US white/black women, ≥9-10 for Mediterranean/Hispanic/Middle Eastern, ≥6 for South American, ≥2-7 for Asian). Also note menstrual regularity, presence of clinical hyperandrogenism signs (acne, alopecia), and any medications that affect androgen levels.
STEP 2 — Rule In / Rule Out
Is the Ferriman–Gallwey score abnormal (above cutoff)? If yes, proceed to measure androgen levels. If no, do not test for elevated androgen levels (unless other clinical evidence of hyperandrogenic disorder exists).
STEP 3 — Classify or Stratify
If total testosterone is normal but sexual hair growth is moderate/severe or mild with clinical evidence of hyperandrogenic disorder (e.g., menstrual disturbance, progression despite therapy), measure free testosterone using a reliable specialty assay (equilibrium dialysis or calculated free testosterone using SHBG and albumin). If total testosterone is elevated, hyperandrogenemia is confirmed.
STEP 4 — Decide
If androgen levels (total or free) are elevated, evaluate for underlying hyperandrogenic etiologies (PCOS, NCCAH, androgen-secreting tumor, Cushing's, etc.). If normal and no other clinical hyperandrogenism signs, consider idiopathic hirsutism and proceed with cosmetic or pharmacologic therapy as appropriate.
Clinical Guardrails / Mimics / Pitfalls
Do not test androgen levels in eumenorrheic women with only unwanted local hair growth (no abnormal hirsutism score) due to low yield. Avoid relying on total testosterone alone in women with mild hirsutism; free testosterone may be more sensitive. Be aware of assay limitations: use reliable specialty assays, avoid immunoassays prone to interference at low female levels. Do not mistake hypertrichosis (generalized nonsexual hair) for hirsutism. Consider medications (valproic acid, anabolic steroids) that can raise androgen levels.
Concrete Clinical Example
A 28-year-old woman presents with facial hair growth and a Ferriman–Gallwey score of 12 (above cutoff for her ethnic background). She has regular menses but reports worsening hirsutism despite shaving. Serum total testosterone is 55 ng/dL (normal <45). Free testosterone is elevated via equilibrium dialysis. Workup reveals polycystic ovarian morphology on ultrasound and oligomenorrhea, leading to a diagnosis of PCOS.
Source: Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, https://doi.org/10.1210/jc.2018-00241
TODO: consider adding scripts/calc.py for the endo-hirsutism-test-androgen-levels-abnormal-score calculator
