New Criteria for the Clinical Diagnosis of Hyperandrogenism in Polycystic Ovarian Syndrome and the Risk of Overdiagnosis

The excess of body hair in women is a frequent problem at the clinic that interferes with their femininity and selfesteem,1 and requires attention from physicians. Classically, hirsutism is the increase of terminal hair in body regions common in the male pattern. In general, hirsutism is associatedwith hyperandrogenism, but not in all of the cases. In 30 to 50% of the women with mild symptoms, high androgen levels are undetected.1 Polycystic ovarian syndrome (PCOS) is the most common cause of hirsutism and corresponds to three out of every four cases. Adrenal dysfunction (Cushing syndrome and enzymatic deficiencies) is the second cause, followed by hypothyroidism, hyperprolactinemia, and androgen-producing tumors (ovarian or adrenal). Certain drugs, mainly anabolicandrogenic steroids, can determine cutaneous hyperandrogenism.2 These clinical situations are part of the differential diagnosis of PCOS, since its manifestations are translated by the exacerbation of androgenic action. Although androgen levels in the circulation may not be elevated, the appearance of hair may be an exaggerated action of androgens in effector organs (in this specific case, in the hair follicle) with other important clinical implications from themetabolic point of view. According to the literature, the major metabolic impairment factor in PCOS patients is undoubtedly the hyperandrogenism resulting from insulin resistance found in these women.3 Hyperandrogenism and hyperinsulinism will trigger important metabolic alterations, such as dyslipidemias, glucose intolerance, diabetes mellitus, vascular inflammatory processes, and themetabolic syndrome itself. In addition to being diagnostic criteria, excess androgens are an important part of the disease pathophysiology and should be tackled in the treatment of patients. Thus, androgen dosages and the search for signs of hyperandrogenism are essential in approaching patients with suspected PCOS.4 When evaluating hyperandrogenism in women with suspected PCOS, some considerations must be made in the light of new concepts about the disease. The conventional dosage of circulating levels of testosterone is quite inaccurate the female gender,4 and sometimes does not reveal the hyperandrogenism that determines less intense forms of hirsutism. In fact, a quarter of hirsute women with PCOS do not have the corresponding hyperandrogenism (testosterone, androstenedione, and dehydroepiandrosterone sulfate), which may raise doubts about the diagnosis. In general, this is determined by biochemical tests employing radioimmunoassay or electrochemiluminometric methods, inwhich the calibration curve of the kit is the same as that developed for the male sex. In part, this may explain the noncorrelation between serum levels and the level of hirsutism. There are more sensitive methods, such as liquid or gas chromatography coupledwithmass spectrometry, but they are unfeasible in the clinical practice, given their high costs. Because of this difficulty in the laboratory diagnosis of PCOS, the clinical evaluation of hyperandrogenism through its more frequently observed manifestations, such as acne and hirsutism, becomes relevant.2–4 Therefore, the evaluation of hirsutism is important for the clinical diagnosis and for the initiation of treatment. In 2018, Teede et al5 organized amajor and careful review of the recommendations for the diagnosis and treatment of womenwith PCOS. Acne, alopecia, and hirsutism aremarkers of cutaneous hyperandrogenism in this guideline. Researchers also suggested the Ferriman-Gallwey (F-G) index as a tool for the diagnosis and follow-up of women with PCOS and hirsutism. However, the great doubt of some researchers is José Maria Soares Júnior's ORCID is https://orcid.org/0000-00030774-9404.